Central Diabetes Insipidus in Children as a Diagnostic Challenge.

Central diabetes insipidus (CDI) is a disorder in the pediatric population resulting from antidiuretic hormone deficiency. The excessive production of dilute urine characterizes it and manifests with polyuria, nocturia, and polydipsia. The diagnostics of CDI is often challenging, especially concerning the underlying condition of the disease. This article highlights the diverse clinical presentation of children with CDI and diagnostic difficulties among patients with polyuria and polydipsia. The article also reviews the etiology, symptoms, diagnostic workup, and management of CDI. We present 4 pediatric patients (aged 3-13.5 years) diagnosed with CDI of different etiology: 1 due to septo-optic dysplasia/optic nerve hypoplasia and 3 due to acquired processes such as Langerhans cell histiocytosis and germ cell tumor in 2 patients. Central diabetes insipidus was the first manifestation of a tumor or granuloma in all presented patients with acquired pathology. The patients sometimes need long-term follow-up to establish the proper final diagnosis.

CDON gene contributes to pituitary stalk interruption syndrome associated with unilateral facial and abducens nerve palsy.

The relationship between congenital defects of the brain and facial anomalies was proven. The Hedgehog signaling pathway plays a fundamental role in normal craniofacial development in humans. Mutations in the sonic hedgehog (SHH) signaling gene CDON have been recently reported in patients with holoprosencephaly and with pituitary stalk interruption syndrome (PSIS). This study's aim was an elucidation of an 18-year-old patient presenting PSIS, multiple pituitary hormone deficiency, and congenital unilateral facial and abducens nerve palsy. Additionally, bilateral sensorineural hearing loss, dominating at the right site, was diagnosed. From the second year of life, growth deceleration was observed, and from the age of eight, anterior pituitary hormone deficiencies were gradually confirmed and substituted. At the MRI, characteristic triad for PSIS (anterior pituitary hypoplasia, interrupted pituitary stalk and ectopic posterior lobe) was diagnosed. We performed a comprehensive genomic screening, including microarrays for structural rearrangements and whole-exome sequencing for a monogenic defect. A novel heterozygous missense variant in the CDON gene (c.1814G > T; p.Gly605Val) was identified. The variant was inherited from the mother, who, besides short stature, did not show any disease symptoms. The variant was absent in control databases and 100 healthy subjects originating from the same population. We report a novel variant in the CDON gene associated with PSIS and congenital cranial nerve palsy. The variant revealed autosomal dominant inheritance with incomplete penetrance in concordance with previous studies reporting CDON defects.

SEMA3A and IGSF10 Are Novel Contributors to Combined Pituitary Hormone Deficiency (CPHD).

Background: The mutation frequencies of pituitary transcription factors genes in patients with combined pituitary hormone deficiencies (CPHD) vary substantially between populations. However, apart from PROP1 the mutation rate of other genes is low and for almost half of the patients with CPHD the routine sequencing of known genes is unsuccessful in the identification of genetic causes. Methods: A cohort of 66 sporadic and nine familial CPHD cases (80 patients in total) were subjected to initial testing of the genes PROP1, POU1F1, LHX3, LHX4, and HESX1 using a targeted gene panel and MLPA. In patients who tested negative, a whole exome sequencing approach was employed. Results: In nine of the familial cases and 32 of the sporadic patients mutations in the PROP1 gene were found (the common pathogenic variants included c.301_302delAG and c.150delA). Mutations were also found in genes so far not related directly to CPHD. A unique homozygous and clinically relevant variant was identified in the SEMA3A gene, which may contribute to neural development and his phenotypic spectrum including short stature and isolated hypogonadotropic hypogonadism (IHH). Another pathogenic variant p.A1672T was found in the IGSF10 gene reported to be responsible for delayed puberty and neuronal migration during embryogenesis. Several suspected novel but predicted benign variants were also identified for the CHD7, WDR11 and FGF17 genes. Conclusion: Although PROP1 defects account for a majority of CPHD patients, identification of rare, less frequent variants constitutes a big challenge. Multiple genetic factors responsible for CPHD are still awaiting discovery and therefore the usage of efficient genomic tools (i.e., whole exome sequencing) will further broaden our knowledge regarding pituitary development and function.

Molecular Detection and Incidence of Y Chromosomal Material in Patients with Turner Syndrome.

The presence of a Y chromosome in patients with Turner syndrome (TS) is a risk factor for the development of gonadal tumor and/or virilization. With conventional cytogenetic analysis, some cells containing a Y chromosome can be missed. The aim of this study was to determine the presence and incidence of Y chromosome-derived material in TS patients using PCR and the markers SRY, DYZ1, DYZ3, DYS132, ZFY, and TSPY. Fifty-five TS patients (aged 5.5-26.75 years) were analyzed. A total of 17/55 (30.9%) were Y-positive, but only 7/17 had a Y chromosome in their karyotype and underwent gonadectomy. In 2 of these patients (28.6%), histopathologic examination revealed gonadoblastoma and dysgerminoma, respectively. In 8 patients in the studied group (8/55; 14.5%), the TSPY gene was detected, and the SRY gene (or a fragment) was identified in 9(3)/55 patients. No coding region mutations were observed in these SRY-positive patients. In conclusion, we have shown a high prevalence of Y chromosomal material in TS. Y markers were also observed in patients who had no Y chromosome in their karyotype, and PCR is very precise in detecting the presence of genetic material from the Y chromosome. Further follow-up of these Y-positive TS patients is mandatory.

[Y chromosome in Turner syndrome]. / Chromosom Y w zespole Turnera.

Turner syndrome (TS) is an inherited genetic disorder caused by numerical and/or structural chromosome X aberrations occurring at a frequency of 1:1200-1:2500 live-born girls. The most common karyotype is X chromosome monosomy (45,X) (approximately 50-60% of cases). Approximately 5-6% of patients may have abnormal Y chromosome or mosaicism characterized by the coexistence of 45,X cell line with cell line in which all or part of chromosome Y is present. In patients with TS who have all or fragmented genetic material from chromosome Y there is a substantial risk of cancerous lesions in these dysgenetic gonads. This paper stands for the review of the current knowledge on the genetic material of the Y chromosome in TS, especially in view of the risk of developing malignancies such as gonadoblastoma and dysgerminoma.

Exome sequencing reveals two novel compound heterozygous XYLT1 mutations in a Polish patient with Desbuquois dysplasia type 2 and growth hormone deficiency.

Desbuquois dysplasia type 2 (DBQD2) is a rare recessively inherited skeletal genetic disorder characterized by severe prenatal and postnatal growth retardation, generalized joint laxity with dislocation of large joints and facial dysmorphism. The condition was recently described to result from autosomal recessive mutations in XYLT1, encoding the enzyme xylosyltransferase-1. In this paper, we report on a Polish patient with DBQD2 who presented with severe short stature of prenatal onset, joint laxity, psychomotor retardation and multiple radiological abnormalities including short metacarpals, advanced bone age and exaggerated trochanters. Endocrinological examinations revealed that sleep-induced growth hormone (GH) release and GH peak in clonidine- and glucagon-induced provocative tests as well as insulin-like growth factor 1 (IGF-1) and IGF-binding protein-3 levels were all markedly decreased, confirming deficiency of GH secretion. Bone age, unlikely to GH deficiency, was significantly advanced. To establish the diagnosis at a molecular level, we performed whole-exome sequencing and bioinformatic analysis in the index patient, which revealed compound heterozygous XYLT1 mutations: c.595C>T(p.Gln199*) and c.1651C>T(p.Arg551Cys), both of which are novel. Sanger sequencing showed that the former mutation was inherited from the healthy mother, whereas the latter one most probably occurred de novo. Our study describes the first case of DBQD2 resulting from compound heterozygous XYLT1 mutation, expands the mutational spectrum of the disease and provides evidence that the severe growth retardation and microsomia observed in DBQD2 patients may result not only from the skeletal dysplasia itself but also from GH and IGF-1 deficiency.

Pituitary Microsomal Autoantibodies in Patients with Childhood-Onset Combined Pituitary Hormone Deficiency: an Antigen Identification Attempt.

The role of autoimmunization in the pathogenesis of pituitary disorders is poorly understood. The presence of pituitary autoantibodies (APA) has been detected in various pituitary disorders. Their role, however, remains elusive. Childhood-onset combined pituitary hormone deficiency (CPHD) may be caused by environmental or genetic factors. In some of patients, causes of the disease remain unclear and contributions of autoimmune processes have been postulated. The aim of this study was to identify the microsomes-derived pituitary antigens (MPA) as potential immunogenic autoantigens in patients with hypopituitarism, therefore 62 CPHD patients, 100 healthy controls and five autoimmune polyglandular syndrome type II (APS II) patients were included in the study. The clinical evaluation included hormonal tests and magnetic resonance imaging of the pituitary. The sources of MPA were pituitary glands taken from autopsies. Isolated MPA were then separated on SDS-PAGE gel and incubated with sera obtained from patients and controls. Microsomal APA were detected using Western blot and radioimmunological method. In all CPHD and APS II patients and in 9 % individuals from control group marked immunoreactivity was detected against MPA. Antibodies showed high affinity to 67, 60, 50 and 36 kDa MPAs. Since the identified autoantigens were of unknown nature, an in silico exploration of UniProt database was applied and indicated their possible relationship with chaperones, golgins and already known autoantigens like GAD67. Reactivity against MPA indicates that these proteins certainly play a role in the processes undergoing within pituitary of CPHD patients. The identification and further detailed studies on their role in the pathogenesis of CPHD should be continued.

The usefulness of the GHRH stimulation test in the diagnostics of growth hormone deficiency in children.

INTRODUCTION: Stimulation tests form the basis for the diagnostic process in growth hormone deficiency (GHD). One of these tests uses the GH releasing hormone (GHRH). This provides the potential to differentiate patients with pituitary dysfunction from patients with hypothalamus abnormalities. However, the routine use of the GHRH test is still being debated. The aim of this study was to assess the diagnostic usefulness of the GHRH test in the diagnostics of GHD. MATERIAL AND METHODS: The study group consisted of 20 prepubertal children with GHD. In all the children, one of the performed stimulation tests was the GHRH test. RESULTS: The results showed that the mean peak concentration of GH in the GHRH test was 14.7 ± 11.3 ng/mL. In eight children the MRI showed pituitary hypoplasia, in one patient pituitary hypoplasia and pituitary stalk agenesis, and in one patient septo-optic dysplasia. All patients with pituitary malformations, except for one patient with a hypoplastic pituitary gland, presented GH levels < 10 ng/mL in the GHRH test. The sensitivity of the GHRH test in the diagnostics of GHD was 45%. CONCLUSIONS: The high correlation between the GHRH test and anatomical changes in the pituitary provides this test with a high predictive value. In individual clinical cases, knowledge about the level of damage in the hypothalamic-pituitary area can determine diagnostic and therapeutic procedures.

The role of the immune system and cytokines involved in the pathogenesis of autoimmune thyroid disease (AITD).

Autoimmune thyroid disease (AITD) is the most common organ-specific autoimmune disorder. AITD development occurs due to loss of immune tolerance and reactivity to thyroid autoantigens: thyroid peroxidase (TPO), thyroglobulin (TG) and thyroid stimulating hormone receptor (TSHR). This leads to infiltration of the gland by T cells and B cells that produce antibodies specific for clinical manifestations of hyperthyroidism in Graves' disease (GD) and chronic autoimmune thyroiditis (cAIT). In addition, T cells in Hashimoto's thyroiditis induce apoptosis in thyroid follicular cells, leading ultimately to the destruction of the gland. Cytokines are involved in the pathogenesis of thyroid diseases working in both the immune system and directly targeting the thyroid follicular cells. They are involved in the induction and effector phase of the immune response and inflammation, playing a key role in the pathogenesis of autoimmune thyroid disease. The presence of multiple cytokines has been demonstrated: IL-1alpha, IL-1b, IL-2, IL-4 , IL-6, IL-8, IL-10, IL-12, IL-13, IL-14, TNF-alpha and IFN-gamma within the inflammatory cells and thyroid follicular cells. Finally, cytokines derived from T cells can directly damage thyroid cells, leading to functional disorders and may also stimulate the production of nitric oxide (NO) and prostaglandin (PG), thus increasing the inflammatory response in AITD. Immunological mechanisms involved in the pathogenesis of AITD are strongly related to each other, but differences in the image of cAIT and GD phenotype are possibly due to a different type of immune response observed in these two counteracting clinical thyroid diseases. This article describes the potential role of cytokines and immune mechanisms in the pathogenesis of AITD.

Treatment of cartilage-hair hypoplasia with recombinant human growth hormone.

Cartilage-hair hypoplasia (CHH) is an autosomal recessive disorder characterized by short stature, hypoplastic hair and humoral immunity disorders. It is a mutation in the RMRP gene, located on chromosome 9p13.3, that leads to CHH. There is no special treatment for short stature in CHH. The efficacy and safety of recombinant human growth hormone (rhGH) therapy in CHH is still under discussion. The present study describes the case of a girl with CHH who was treated with rhGH. The rhGH treatment had a significant effect on the height gain: the height SD score was changed from -4. to -2.98 after 4 years 7 months of treatment. rhGH therapy should be considered as a treatment modality for CHH, and insulin-like growth factor (IGF)-1 and IGF-binding protein 3 concentrations should be closely monitored, particularly because of the increased cancer risk that is a characteristic feature of CHH.

[Estimation of growth hormone secretion during sleep as a screening test in the diagnosis of GH deficiency]. / Ocena wydzielania hormonu wzrostu po zasnieciu jako badanie przesiewowe w diagnostyce somatotropinowej niedoczynnosci przysadki.

BACKGROUND: Because of many disadvantages of growth hormone (GH) stimulation tests the diagnosis of growth hormone deficiency (GHD) is still problematic for the clinician. THE AIM of the study was the estimation of diagnostic usefulness of the GH provocation tests and basal IGF-I concentration measurement in the diagnosis of GHD. MATERIAL AND METHODS: The study group consisted of 180 children with short stature diagnosed in the Department of Pediatric Endocrinology and Diabetes in the years 1998-2003. Pharmacological stimulation test with insulin, clonidine, glucagon and L-dopa were used. GH concentration in physiological test after the onset of sleep was also measured. In 60 patients IGF-I concentration was estimated. For statistical analysis Spearman test was used. RESULTS: The highest mean GH concentrations (19.18 microl U/ml) and GH peaks (26.39 microl U/ml) were observed in sleep test. IGF-I concentration was correlated with GH concentration levels in physiological test after onset of sleep (r=0.4; p<0.05). CONCLUSIONS: Sleep is the strongest stimulatory agent for GH secretion. The estimation of GH secretion after the onset of sleep can be used as a screening test in the diagnosis of GHD. Because of many diagnostic problems in estimation of pituitary function the auxologic parameters should be considered as the most important part in the diagnostic work-up of children with short stature due to GHD.

The effects of growth hormone treatment in patients with somatotropin deficiency during their developmental age.

INTRODUCTION: In Poland treatment with growth hormone of adolescent patients dates back to 1964. Till 1993 the therapy was conducted in an interrupted manner, depending on the periodic availability of the drug. The data form such forms of therapy suggested that the end height within 3rd centile was achieved only by a portion of treated patients. Since 1995 the growth hormone is used in continuous therapy, which allows to sum up the effects of the therapy, including the growth rate and end height. MATERIAL AND METHODS: A total of 117 children and adolescent of both sexes, aged 4.6 to 18.1 years, with diagnosed somatotropic or multihormonal pituitary insufficiency were included in the study. All of them were treated with growth hormone and had an analysis of growth rate and end height. RESULTS: In the first 6 months of growth hormone treatment the growth rate achieved 10.4 cm/year in boys and 10.0 in girls and showed no correlation with maturation status. In the second half of the year the growth rate declined slightly. During the remainder of the therapy the growth rate markedly declined, and this effect was most notable in girls. In 93% of patients after the end of therapy the final height was no different than the expected height. CONCLUSIONS: 1. The growth rate in first half a year of the treatment was 3 times higher than before the beginning of therapy. 2. In the second half of the first year the growth rate slightly declined. 3. In following years the growth rate declined notably. 4. The final achieved height in most of the patients does not differ from the prognosed height.

[High level of hsCRP in patients with Graves' ophthalmopathy--preliminary study]. / Wysokie stezenie hsCRP u pacjentów palacych z oftalmopatia w przebiegu choroby Gravesa--doniesienie wstepne.

UNLABELLED: C-Reactive Protein (CRP) levels are used to indicate the presence of an inflammatory process that may be caused by bacterial infection or pathological processes. The objective of this study was to compare the levels of CRP and hsCRP (high sensitivity CRP) in smoking and non smoking patients with Graves' Ophthalmopathy (GO). Study included 59 hyperthyroid patients (age > 18 years, 50 females, 9 males, mean +/- SD: age 34 +/- 16) with varying degrees of severity of GO (classification according to NOSPECS) with hyperthyroidism prepared to radioiodine therapy. Smoking status was determined by Fagerström test and Brinkman's index. CONCLUSIONS: 1. Smoking additionally stimulates inflammatory processes in the patients with Graves' Ophthalmopathy, 2. Smoking patients with